






Environmental Affairs
Infection Control
Occupational Health
Patient Safety
Radiation Safety
Risk Management
Security
Brigham and Women’s Hospital:
Committed to Quality of Work Life
BWH BLUE BOOK
The Staff
Guide
to a Safe and
Healthy
Working
Environment
INTRODUCTION
Brigham and Women’s Hospital prides itself on excellence. Dedicated to serving the needs of
the community, it is our mission to deliver the highest quality of healthcare to patients, train the
next generation of health care professionals, and expand the boundaries of medicine through
research. This excellence is continuously achieved through the personal commitment of every
employee to this mission.
Our employees are our greatest asset and for this reason, your safety is of paramount concern.
BWH is committed to providing all of its employees with a safe and healthy working
environment. BWH has taken great measures to ensure that policies and protocols have been
instituted to protect you and the patients that you serve. As employees of the hospital, it is
important for you to know that there are a variety of health and safety resources available to
you through departmental programs established with Environmental Affairs, Infection Control,
Occupational Health Service, Patient Safety, Radiation Safety, Risk Management, Engineering
and Security. In order to ensure optimal safe and healthy working conditions, you must
become familiar with these guidelines and become dedicated to continuously updating your
knowledge and training.
This booklet introduces you to the basic fundamentals of each of these health and safety
programs. Within each section you will also find references that will help you learn more about
the health and safety policies through participation in training programs or further readings.
We strongly encourage your involvement in these programs, and thank you for your
commitment to excellence.
1
TABLE OF CONTENTS
I.
EMERGENCY CODES …………………
3
II. BWH ENVIRONMENTAL AFFAIRS…
Overview
4
Indoor Environmental Quality
Fire Emergency
Fire Safety
Fire Extinguisher Training
Internal/External Disasters
Laboratory Safety
Personal Protective Equipment
Hazardous Chemical Spills
Hazardous Waste & Disposal
II. BWH RADIATION SAFETY OFFICE… 13
Overview
Frequently Asked Questions
III. BWH INFECTION CONTROL ………… 18
Overview
Standard Precautions
Transmission-Based Precautions
Handling Contaminated Items
Safe Work Practices
Regulated Medical Waste
Hand Hygiene Procedures
IV. BWH OCCUPATIONAL HEALTH SERVICE ... 26
Overview
Immunization Requirements
Tuberculosis Screening
Facts on Tuberculosis
Work-Related Illness/Injury Reporting
Exposure to Blood/Bodily Fluids
Information on HIV
Information on Hepatitis B
Information on Hepatitis C
Reportable Conditions
V. BWH PATIENT SAFETY TEAM ………………
Overview
36
Patient Safety Terminology
Medication Safety
VI. BWH RISK MANAGEMENT DEPARTMENT… 40
Overview
Incident Reporting
VII.BWH SECURITY …………………………………
43
IX. EQUIPMENT REPAIR/REMOVAL CONTACTS 45
X. BUILDING SYSTEMS FAILURES AND
CONTACTS ………………………………………….
46
2
EMERGENCY CODES
STAT LINE – All Codes 617-732-6555 or x2-6555
 Code Red –
Fire
 Code Gray –
Security Personnel Needed Urgently
 Code Blue –
Immediate Medical Assistance Needed
 Code Green –
M.D. or Specialty Needed Urgently
 Code White –
Bomb Threat
 Code Pink –
Infant Abduction
 Code Amber –
Disaster Plan in Effect
1
BWH
ENVIRONMENTAL
AFFAIRS
BWH Environmental Affairs
5
Indoor Environmental Quality
6
Fire Emergency
7
Fire Safety
7
Fire Extinguisher Training
8
Internal/External Disasters
9
Laboratory Safety
10
Personal Protective Equipment 10
Hazardous Chemical Spills
11
Hazardous Waste & Disposal
12
2
BWH ENVIRONMENTAL AFFAIRS
ENVIRONMENTAL AFFAIRS
The Department of Environmental Affairs (DEA) administers a variety of health and safety
programs for Brigham and Women’s Hospital (BWH). This section will provide you with a brief
description of certain critical policies and procedures related to environmental health and safety.
For more detailed and comprehensive information, please review the Environmental Safety and
Health Policy Manual available through your Manager, Department Administrator, Safety
Committee Representative, or the Department of Environmental Affairs.
The DEA seeks to ensure that all staff, patients, contractors, and visitors are afforded the
highest level of personal safety and protection at BWH, according to federal, state, and local
guidelines. The responsibilities of the DEA are to:
a. Implement Safety Policies
b. Act as an internal consultant to all hospital departments on
 fire and life safety
 work practices
 air and environmental quality
 laboratory and chemical safety
 safety-related regulatory issues
 environmental compliance
 disaster management
c. Investigate incidents involving possible safety or environmental concerns
d. Provide consultation to the BWH Command Center during internal or external disasters
e. Develop training programs and provides training in the following areas:
 Respirator fit-testing and use
 Laboratory safety
 Chemical handling and waste disposal
 Custom training packages as necessary
Contact Information:
Department of Environmental Affairs: 617-732-7016 or (X2-7016)
Hours:
Monday – Friday
8:00 AM – 4:30 PM
Air quality and other emergencies:
Hazardous chemical spills:
617-732-5700, bb#15000 (24 hours)
STAT Operator: 617-732-6555 (x2-6555)
3
INDOOR ENVIRONMENTAL QUALITY
If you need immediate assistance in finding a remedy to an air quality problem, please page the
Air Quality Pager at 617-732-5700 or x2-5700, beeper#15000 for a response to your concerns.
The pager is staffed 24 hours per day for response to safety emergencies. These air quality
problems may include:
1. Unusual odors
2. Visible dust in the air
3. Excessive stuffiness or apparent stagnant air
If you believe an air quality problem is causing you to experience physical symptoms, page
#15000 and report to Occupational Health Services (or Emergency Department after hours) for
a medical evaluation.
If you feel your environment is too hot or cold, and the situation cannot be corrected using your
local thermostat, please call BWH Engineering at 617-732-6720 or x2-6720.
TO HELP US MAINTAIN ACCEPTABLE AIR QUALITY, ALL EMPLOYEES ARE RESPONSIBLE FOR:

Keeping BWH a fragrance-controlled environment. This means using only minimally-scented
personal care products and not wearing perfumes, aftershave or other products designed to
be perceived by anyone but the user. Patients and/or fellow employees may have
sensitivities to chemicals used in fragrances and may become symptomatic when exposed to
them. Use unscented soaps to bathe and for laundry.

Use only BWH-Approved Cleaning Materials in your workspace. These products have been
reviewed and approved for use by an industrial hygienist. Using other-than-approved
products may have adverse effects on patients and co-workers.
BWH strives for the highest quality of work environment for all employees. If you have
questions or concerns about your work environment, please call the Department of
Environmental Affairs at 617-732-7016 or x2-7016.
4
FIRE EMERGENCY
CODE RED - BWH term for fire emergency – Notification & Response.
A fire emergency constitutes seeing fire or smoke, or smelling something burning.
The following procedures are to be followed during a fire emergency (A-R-C-E).
ALARM
 Pull the fire alarm nearest to the fire.
 Call out “CODE RED” and the room location to alert staff.
 Dial STAT Operator at 732-6555 or x2-6555, say “CODE RED”, give the exact fire location,
and state your name.
RESCUE
 Go to the fire room when alerted.
 Remove the person(s) in immediate danger.
 Close the door(s).
CONTAIN
 Close the doors to all rooms in the zone.
 Ensure that the smoke/fire doors are closed.
EVACUATE
Patient Care Staff:

Move the patients through the fire doors to the safe zone upon the direction of your
supervisor or whoever is in charge at that time.
Non-Patient Care Staff:

Move to the designated safe zone.
All employees are responsible for keeping BWH “Fire-Safe”.

Treat all alarms as a true emergency. When you hear an alarm, check your own
workspace and surroundings for an emergency condition.

Follow your department’s “CODE RED” procedure each time the alarm sounds.
FIRE SAFETY

NOTHING should be STORED:
 in Hallways
 in Corridors
 in Stairways
 in a way that blocks fire doors, fire extinguishers, or other fire
alarm equipment

Ensure that all staff, patients, and visitors are aware of and adhere to the BWH NOSMOKING policy.

Know your Department Fire Evacuation Plan.
5
FIRE EXTINGUISHER TRAINING
BWH does not require employees to use a fire extinguisher. However, the following
guidelines are presented should an employee choose to attempt to extinguish the fire.
There are five classifications of fire:
Class A: Involves wood, cloth, paper, rubber, and many plastics
Class B: Involves flammable liquids, oils, and flammable gases
Class C: Involves electrically energized equipment
Class D: Involves combustible metals such as sodium and magnesium
Class K: Involves combustible leaking oils and greases
Fire extinguishers must match the class of fire being fought. Markings on the extinguisher body
indicate the classes of fire the extinguisher is suited for. Use of the wrong extinguisher can
intensify a fire condition, such as application of water to burning oil, thereby causing the oil to
splatter, flash, and spread.
Some common extinguishers are:
Pressurized Water: For Class A fires
Carbon Dioxide: For Class B & C fires
Dry Chemical: Either for Class B & C fires or for Class A, B, & C fires, depending on the
markings.
Halon: For Class B and C fires
For Class K fires, the proper portable extinguisher is a dry chemical extinguisher of either type,
except in areas where flammable and combustible liquids are stored beyond an incident
amount. In this situation, the travel distance to an extinguisher shall not exceed 50 feet.
There is a fire extinguisher within 75 feet of any occupied space in the building. Staff should
familiarize themselves with the locations and types provided for their work area.
Before attempting to extinguish the fire:
 Alert others in the area to the fire situation.
 Make sure that the fire alarm has been pulled.
 Notify the Stat Operator at 617-732-6555 or x2-6555 of the Code Red.
 Make sure that the fire extinguisher is the proper type for the fire being fought.
 Make sure your back is to a safe and unobstructed exit where the fire will not spread.
If these ALL these criteria are not met, close the door to the fire area, evacuate and
wait for the fire department.
Operating the Portable Fire Extinguisher
Remember the acronym P-A-S-S.
Pull the pin all the way out of the extinguisher handle.
Aim the hose or nozzle at the near edge of the base of the fire.
Squeeze the handle lever all the way closed to discharge the extinguishing agent.
Sweep from side to side, continuing to aim at the base of the fire.
6
IF DISASTER STRIKES
CODE AMBER IS THE AUDIO PAGE FOR A DISASTER AFFECTING THE HOSPITAL.
A Code Amber page includes an announcement of its phase, which describes its
seriousness, and whether the disaster is internal or external to the hospital.
Code Amber - External
Refers to a natural or man-made event that may cause a large influx of patients to the hospital.
 Phases are:
1 - Alert, expected caseload less than 10
2 - Expected caseload 10-20
3 - Expected caseload more than 20
 See BWH Disaster Manual for departmental responsibilities.
 Know your specific role.
 Report to Department Supervisor for further instructions.
 Stand by for further announcements or instructions.
Code Amber - Internal
Refers to an internal event in which patients, staff, and visitors are at risk of injury or to an
event that may lead to decrease or discontinuation of services provided by the Hospital.
 Phases are:
1 - Minimal disruption
2 - Hazardous condition
3 - Evacuation plans implemented
 See Disaster Manual for departmental responsibilities.
 Know your specific role.
 Report to Department Supervisor for further instructions.
 Stand by for further announcements or instructions.
7
LABORATORY SAFETY
The Department of Environmental Affairs provides policies, training, and consultation on all
aspects of laboratory safety, except radiation safety. Annual environmental health and safety
re-training is mandatory for all laboratory staff.
The Research Laboratory training includes:





Storage and use of chemicals
Chemical spill procedures
Personal Protective Equipment
Material Safety Data Sheets (MSDSs)
Use of fume hoods





Hazardous waste management
Fire and life safety
Biological safety
BWH Disaster Plan
Annual Chemical Inventory
Each laboratory staff member must take annual quizzes based on this material. Personnel
working in the Clinical Laboratories, in the Department of Pathology, and as phlebotomists must
pass additional quizzes on the infection control procedures relevant to their work.
Please note that ALL staff, whether employed in laboratories or not, must pass annual quizzes
on bloodborne pathogens and tuberculosis. These two quizzes are maintained as part of each
employee’s departmental personnel record.
Complete descriptions of laboratory and chemical safety procedures can be found in the BWH
Environmental Safety and Health Policy Manual and the BWH Chemical Hygiene Plan.
Please call the DEA for a schedule of training sessions or with any questions at 617-732-7016 or
x2-7016.
PERSONAL PROTECTIVE EQUIPMENT
The Department of Environmental Affairs provides consultation on personal protective
equipment, including respirators, gloves, and other types of protection for laboratory and some
clinical procedures. The DEA also provides respirator fit-testing for protection against
tuberculosis exposure for nurses, patient care assistants, and other clinical personnel.
Please call the DEA for a schedule of fit-testing sessions and with any questions about personal
protective equipment at 617-732-7016 or x2-7016.
8
HAZARDOUS CHEMICAL SPILL OR RELEASE
It is BWH policy that employees be aware of the correct emergency procedures to manage
chemical spills in both clinical and research areas. If you have any questions about how to
proceed, call the Department of Environmental Affairs Monday – Friday 8:00 am to
4:30 pm (617-732-7016 or x2-7016) or the Stat Operator after hours (617-732-6555
or x2-6555) before attempting any cleanup.
The following descriptions present general procedures for management of non- emergency
(small) and emergency (large) chemical spills. Complete details can be found in Appendix F
(Chemical Spill Procedure) of the Chemical Hygiene Plan.
Non Emergency - minor chemical spill
Small spill presenting minimal hazard to a trained employee or to the environment.





Wear appropriate personal protective equipment (gloves, goggles, lab coat).
Absorb spill with appropriate cleanup materials from a chemical spill kit.
Dispose of all cleanup materials as hazardous chemical waste.
Contact Department of Environmental Affairs at 617-732-7016 or x2-7016 and complete
report of incident.
Refer to the Chemical Spill Procedure section of the Chemical Hygiene Plan.
EMERGENCY – major chemical spill
A spill of a large quantity of a chemical, of an extremely hazardous chemical that may present a
hazard to people and the environment, or of a chemical whose effects are unknown.








Remove injured or contaminated persons from the vicinity if you can do so safely.
Alert staff in the immediate spill area to evacuate.
If the spilled material is flammable, turn off ignition sources.
Close doors or otherwise isolate area.
From a safe location, call the STAT Operator (617-732-6555 or x2-6555) and notify your
supervisor. Security will notify emergency response personnel and the Department of
Environmental Affairs.
Begin decontamination of victims and provide medical support if you are appropriately
trained and can do so safely while waiting for emergency response personnel.
Complete report of incident.
Refer to the Chemical Spill Procedure section of the Environmental Health and Safety Policy
Manual for complete details.
9
HAZARDOUS WASTE
A material is designated as a hazardous waste if it falls into one of four hazard categories
defined by the U.S. EPA: Ignitable, Corrosive, Reactive, and/or Toxic. All hazardous waste must
be accumulated in a designated area, which is called a Satellite Accumulation Area, and must
be labeled with the pre-printed waste tags provided by the Department of Environmental
Affairs.
The Department of Environmental Affairs manages BWH’s chemical hazardous waste program
and assists research laboratories, patient care areas, and other hospital departments with the
proper accumulation, collection, and disposal of hazardous chemical waste. Improper disposal
of hazardous materials, including many lab chemicals, batteries, mercury thermometers, and
even cleaning products, is illegal. Please refer to the Environmental Safety and Health Policy
Manual for a complete description of the program. Questions can be answered by contacting
the DEA at 732-7016 or x2-7016.
Hazardous waste pickup can be arranged by completing the Hazardous Chemical Waste Pickup
Form (HCWPU) located both in the Environmental Safety and Health Policy Manual and in the
Chemical Hygiene Plan. Fax completed form to DEA at 617-566-6037.
Hazardous chemical waste should not be confused with biohazardous waste (sharps, biological
materials, etc.), which is handled by Environmental Services (617-732-7130 or x2-7130), or
with radioactive waste, which is handled by Health Physics (617-732-6056 or x2-6056).
617-732-7016
10
RADIATION
SAFETY OFFICE
Radiation Safety Office
14
Frequently Asked Questions
15
11
RADIATION SAFETY OFFICE
The Radiation Safety Office is located within the Department of Health Physics and
Radiopharmacology. Through an extensive Quality Management Program, periodic instruction
and frequent staff visits to radiation areas, the office maintains a safe environment for the
clinical and research use of radiation.
In combination with the regulations by the Massachusetts Radiation Control Program, the
Health Physics Department and Radiation Safety Office are responsible for enforcing the safety
of all BWH employees working with and around radiation sources in the hospital. It is important
that you feel secure and knowledgeable working near or with radiation under these controlled
conditions.
During the past 50 years, radiation has become a necessary tool in research and for diagnosis
and treatment of diseases. There are many different kinds of radiation. They can be separated
into two main categories based on how each acts with atoms: ionizing and non-ionizing.
Examples of ionizing radiation include alpha particles, gamma rays, x-rays, electrons and beta
particles. Non-ionizing radiation examples include microwaves, lasers, ultrasound, and
magnetic fields.
There are many different types of radiation to which we are exposed in the natural world and,
under controlled conditions, in research, industry, and medicine. Natural radiation includes rays
received from the sun (ultraviolet and infrared) as well as cosmic rays from outer space and
radioactivity from the ground. As you are reading this manual, you are being exposed to
natural or background radiation. This exposure is considered to be low and it causes no known
ill effects. Examples of radiation used in research, industry and medicine include radiowaves,
lasers, MRI scanners, CT scanners, x-ray units, and radioactive drugs. Both types of radiation
ionizing and non-ionizing are used to provide the best possible health care to patients.
The following section will provide you with information on radiation with answers to frequently
asked questions by employees.
Contact Information:
Radiation Safety Office:
Location:
Hours:
Emergency on call:
617-732-6056 or x2-6056
Carrie Hall Building, 5th floor
Monday – Friday
8:00 AM – 4:30 PM
BB#33330 (24 hours) – Main campus
BB#11574 – 65 Lansdowne Street
(Dial 617-732-5700 or x2-5700, then bb#)
12
RADIATION SAFETY: FAQ’S
Will I be Exposed to Radiation When Working at BWH?
A certain number of employees work directly with radiation sources in the clinic or research
labs. Radioactive material is kept in special areas and, when not in use is secured. Those who
come in contact with radiation are trained exclusively for this purpose. They will be exposed to
small quantities of radiation and will wear a radiation badge to measure their dose. These
individuals will also receive training based on the type of radiation in their working environment.
Those of you not working directly around these radiation sources will normally not be exposed
to radiation on the job. However, sometimes you might have to work near a radiation source in
a room or with a patient who has been administered radiation treatment.
Become aware of these specialized sites by looking out for various information signs. For
example, a “Caution, Radioactive Material” sign will be on doors to rooms where radioactive
material is used. In the MRI suite, the magnetic field warnings are for individuals wearing
pacemakers. In the operating room, a “Laser On” sign signifies its use. Every time an x-ray
machine is used, an
“X-Ray” light goes on outside the room.
Portable x-ray machines are used on patient care units and in the operating room. Here there
will be some scattered radiation from the patient, but it is barely measurable from six feet
away. Inpatients receiving radiation therapy emit some radiation, but outside their room the
exposure is very low.
It is important that you know your own work environment and become aware of any possible
sources of radiation.
How Does Radiation Interact With My Body?
Ionizing radiation is energy emitted from a radioactive atom or from a specialized machine, like
a x-ray unit. The emitted radiation can be in several forms, as particles or waves (like light or
sound waves). Radiation in the form of an alpha or beta particle can be stopped by a lab coat,
gloves, or, several layers of skin.
If the radiation is a gamma ray or x-ray, it will penetrate tissue. When the radiation penetrates
the body, more organs are exposed. In general the radiation may pass through a cell
producing no effect, it may temporarily injure the cell, or it may cause the cell to transform or
to die. In most cases, if radiation damage occurs, it is repaired and the cell continues to
function normally. This especially holds true when considering the small amount of radiation
handled by workers at BWH. Only when many cells are subjected to severe or repeated high
radiation exposure is there a possibility for severe damage. This concept is used when treating
cancer cells with radiation.
(continued)
13
Non-ionizing radiation (from lasers or microwave sources) affects cells by heating or exciting
atoms. You are probably familiar with microwave ovens and the heating of various foods.
Microwaves will cause tissue heating, which is a minor effect during MRI scans. Lasers can be
hazardous to the skin and the eyes. Ultra violet light, which is used in certain operating rooms
to kill bacteria, also can effect the skin and eyes.
The high magnetic field associated with MRI scans has no known biological hazards. However,
metal objects, internal pacemakers, wristwatches, and credit cards are affected. Specific
precautions will be explained to you if these sources are part of your work environment.
How is Radiation Measured?
Ionizing radiation is usually measured with a Geiger-Muller (GM) survey meter (often called a
Geiger counter). Detected radiation can be expressed in counts per minute, or in terms of
exposure units called the Roentgen. A patient’s or health care worker’s dose unit is called the
rad (radiation absorbed dose), or a dose equivalent unit called the rem. In hospital settings, all
three units are approximately the same. Radiation units are also expressed in International
units where 100 rad = 1 Gray and 100 rem = 1 Sievert.
Natural background radiation (from the sun, ground, etc.) adds up to about
0.30 rem every year. For those wearing a radiation badge, the unit signifying a 1 to 2 month
exposure history is in terms of millirem (1/1000 of a rem). Most badge readings come back as
“M”, meaning minimal exposure < 1 milliRem.
Non-ionizing radiation (from lasers, microwave sources) is measured in terms of absorbed
energy (watts/kilogram, joules/kilogram). The earth's natural static magnetic field is 0.5 Gauss
(G). The magnetic field in a MRI machine is often measured in Gauss (G), and sometimes in
Tesla. (One Tesla = 10,000 Gauss)
A typical MRI scanner generates an internal field of 5,000 - 30,000 G, and external magnetic
fields near the unit may be in hundreds of Gauss. Individuals wearing pacemakers are not
allowed to be in a 5 G or greater field, and therefore, must avoid MRI facilities and other strong
magnetic field sources.
Is Even a Little Radiation Harmful to My Health?
We are exposed to natural background radiation all the time. If we require medical or dental xrays we are exposed to additional radiation. The total exposure depends on the type of exam.
The benefit of having the diagnostic exam almost always outweighs the risk from the radiation
exposure. We generally accept this amount of radiation exposure without concern for our
health. When a very high dose is received, such as during radiation therapy treatments, there
is a small additional risk for developing cancer sometime in the future.
The allowed radiation limit for employees (5000 millirem per year) is far below those levels
which have contributed to the development of cancer. Rarely do radiation workers receive even
10% of the annual allowable limit.
14
What if I Become Pregnant?
Occasionally an employee who is handling radiation (for example, a lab worker or nurse caring
for a therapy patient) becomes pregnant. Quite naturally, there is concern for the health of the
developing fetus. The worker can declare her pregnancy to the Radiation Safety Office where
her work and radiation dose history will be reviewed. She may continue in her work, change
her schedule or job tasks, or avoid exposure to the radiation completely, depending on the fetal
radiation risk and specific hospital policy.
The risk of potential problems is related to the amount of radiation received and how many
weeks pregnant the worker is. In general, the occupational limit for the developing fetus for a
radiation worker is 50 millirem/month. Workers in the hospital rarely have readings that high.
Also, 50 millirem/month is far below the exposure level which has been shown to cause fetal
changes.
If I have Concern About My Possible Radiation Exposure, Whom Shall I Contact?
You are encouraged to contact the Radiation Safety Office @ 617-732-6056 or x2-6056 if
questions arise regarding radiation.
15
BWH INFECTION
CONTROL
BWH Infection Control
19
Standard Precautions
20
Transmission-Based Precautions 21
Handling Contaminated Items
22
Safe Work Practices
23
Regulated Medical Waste
24
Hand Hygiene Procedures
25
16
INFECTION CONTROL
The primary aim of the Brigham and Women’s Hospital Infection Control Department is to
develop and maintain an environment that minimizes the risk of acquiring or transmitting
infectious agents to patients, hospital staff and visitors.
The mission of the Infection Control program includes the following:
1. To provide surveillance, analysis and reporting of nosocomial infections (infections
originating or taking place in a hospital) to health care providers.
2. To develop policies and procedures for minimizing transmission of infections within the
hospital, ambulatory care areas, and areas that provide specialized patient care or
diagnostic services.
3. To work with managers/department heads to monitor and improve compliance with
infection control policies and procedures.
4. To identify and investigate unusual infections or “clusters” of infection and make
recommendations for process improvement.
5. To ensure that policies and procedures and educational activities are in compliance with
regulatory requirements.
Contact Information:
Infection Control Department:
Location:
Hours:
617-732-6785 or x2-6785
617-525-2013
TR-80
Monday - Friday
7:30 AM–5:00 PM
17
STANDARD PRECAUTIONS
Standard Precautions are designed both to prevent transmission of bloodborne pathogens to
health care workers (previously covered under universal precautions) and to prevent hospital
spread of pathogens between patients via hands of health care workers. Standard Precautions
apply to all patients regardless of their diagnosis or presumed infection status. Good hand
hygiene (handwashing/hand antisepsis) is the standard of quality patient care.
The principal components of Standard Precautions are:
1. Hand disinfection is the single most important means of preventing the spread of infection.
Hands must be washed with either soap and water or disinfected with a waterless hand gel
prior to and following any direct contact with a patient’s skin, mucous membranes, body
fluids, any contaminated items, and after removing gloves, gowns or respiratory protection
devices.
2. Wear gloves when you may be touching blood, body fluids, secretions, mucous membranes,
non-intact skin and any contaminated items. Remove gloves promptly after use and
disinfect hands with the waterless hand gel or wash your hands with soap and water if
visibly soiled with dirt, blood or body fluids.
3. Wear gowns when skin or clothes are likely to be contaminated with blood, body fluids, and
secretions. Remove gown promptly after use and disinfect your hands with the waterless
hand gel or use soap and water if visibly soiled with dirt, blood or body fluids.
4. Wear face protection (either goggles or prescription glasses with solid side shields and a
mask or a chin length face mask) during procedures that are likely to generate splashes or
sprays of blood, body fluids or secretions. Remove the face protection promptly after use
and disinfect your hands with the waterless hand gel or wash your hands with soap and
water if visibly soiled with dirt, blood or body fluids.
18
TRANSMISSION-BASED PRECAUTIONS
Transmission-based precautions are designed for patients documented or suspected to be
infected with highly transmissible or epidemiologically important pathogens when additional
precautions are needed.
There are three types of Transmission-Based Precautions: Airborne Precautions, Droplet
Precautions and Contact Precautions. Standard Precautions must be used in addition to
transmission-based precautions.
1. Airborne Precautions are designed to reduce the risk of airborne transmission of infectious
agents (e.g., Mycobacterium tuberculosis, Chickenpox).
2. Droplet Precautions are designed to reduce the risk of transmission of infectious agents by
respiratory droplets (e.g., meningococcal meningitis)
3. Contact Precautions are designed to reduce the risk of transmission of microorganisms by
direct contact (e.g., vancomycin resistant Enterococcus (VRE), methicillin-resistant
Staphylococcus aureus (MRSA) and Clostridium difficile.
The Manual of Precautions lists precautions and special instructions for each disease.
Precaution information sheets are available. They contain specific information on each type of
precaution. Fact Sheets detail information about diseases such as MRSA, VRE, TB and Varicella.
All information is available on BICS. When in the BICS main screen, go to “Handbook”, then
“Infection Control” (or type “info” at the BICS prompt, type “E”mployee Resource Guide, type
“IP” (Infection Precautions), then type “man” (manual).
Precautions signs are available from the Transport Department.
19
HANDLING CONTAMINATED ITEMS
1. Linens:
Use a blue plastic linen bag as all linen is treated as contaminated.
2. Instruments:
a. Soak and scrub instruments in enzymatic detergent solution.
b. Use appropriate disinfection or sterilization procedures per Infection Control guidelines.
(Refer to Processing/Storage of Patient Equipment and Supplies, located on BICS under
Handbook, under Infection Control).
c. Items for CPD are transported in puncture-resistant containers with biohazard labels.
3. Environment:
a. Use only hospital-approved germicides and disinfectants.
b. Clean blood or body substance spills as follows.
1) Limit traffic to area
2) Use gloves and paper towels; never pick up broken glass with your hands -- use
cardboard or plastic scoops.
3) Small spills: Use Aseptiwipes to clean spill. Discard in biohazard container.
4) Large spills: Apply disinfectant Chlorasorb or Premisorb to area, remove with
cardboard/plastic scoop and place in biohazard container. Environmental Services
may also be called for clean up.
4. Equipment:
Noncritical items (e.g., wheelchairs, stretchers, exam tables, etc.):
a. Use a hospital-approved germicide
b. Wear gloves
c. Wipe entire surface of item
Semicritical (e.g., endoscopes) and critical items (e.g., biopsy forceps):
Refer to the Infection Control departmental guidelines and Policy for Processing and
Storage of Patient Equipment and Supplies (on BICS) for specific guidelines.
20
SAFE WORK PRACTICES
1. Use sharps with engineered sharps injury protection features such as safety IV catheters,
sheathed syringes, sheathed butterfly needles, safety needles, safety scalpel, point lock and
blood transfer set, in place of needles/sharps without injury protection features whenever
possible. ACTIVATE THE DEVICE.
2. Use Safe Work Practices (located in BICS – Under “UT” -Utilities, go to “EMP”- Employee
Resource Guide, select “IP” – Infection Control Information and choose “Safe Work
Practices.”)
3. Refer to departmental task sheet or Clinical Practice Manual for appropriate barriers (gloves,
gowns, face protection) to wear while performing specific tasks.
4. Use resuscitation devices instead of mouth-to-mouth resuscitation.
5. Never recap needles by hand.
6. Wear face protection (mask and either goggles or prescription glasses with solid side
shields, or chin length face shield) when assisting with procedures that generate aerosols of
blood/body fluids or during any procedure likely to generate splashes into your face.
21
REGULATED MEDICAL WASTE
In accordance with the ‘Safe Work Practices Policy’, as outlined in the Infection Control Manual,
Brigham and Women’s Hospital provides and requires that safe needle practices and/or devices
be used in all procedures requiring the use of needles.
1. Use extreme caution when handling potentially injurious and contaminated sharps (e.g.,
needles, scalpels, blades, pipettes, glass slides, disposable razors).
a. Discard immediately after use in puncture-resistant containers or needleboxes.
b. Do not recap contaminated needles by hand.
c. Do not break, cut, or bend needles.
d. Use sharps with engineered sharps injury protection features to help prevent exposures.
2. Discard solid (non-sharps) regulated medical waste (i.e., items heavily soiled with blood) in
designated containers:
Refer to Exposure Control Plan (located on BICS, under Handbook, in Infection Control).
3. Discard liquid infectious waste into flushing sink or hopper (use personal protective
equipment and take care not to contaminate environment). Items that do not require
emptying (e.g., chest tubes, IV tubing, suction canisters), should be disposed of into a
designated biohazard waste container.
4. Orange/red biohazard labels, red trash bags, and red impervious containers are used to
identify regulated medical waste.
22
RECOMMENDED HAND HYGIENE PROCEDURE
Hand disinfection has been shown to be the single most important measure to prevent the
spread of infection. Hands should be washed or disinfected BEFORE and after all
patient contacts, contact with contaminated equipment/instruments, before any
procedure, immediately after removing gloves, before leaving a lab, and before
eating.
1. If hands are visibly soiled with dirt, blood or body fluids, use vigorous scrubbing with soap
and water for at least 10 seconds and thorough rinsing with water to remove contaminants.
a.
b.
c.
d.
e.
Pump or pull paper towel dispenser to have towels readily accessible.
Turn on faucet.
Wet hands first.
Apply handwashing soap (in some areas this may be an antimicrobial soap).
Work up a lather, using friction over all surfaces, including fingers and wrist area and
between fingers.
f. Rinse hands well, in a downward position.
g. Take the paper towels and pat the hands dry, to avoid unnecessary abrasion of the
skin.
h. Turn off faucet with another dry paper towel.
i. Discard towels in trash receptacle.
2. If hands are not visibly soiled with dirt, blood or body fluids, use the one-step waterless
hand gel to disinfect hands.
a.
b.
Pump a nickel-sized amount of gel into hands.
Rub your hands together until they are dry.
23
BWH
OCCUPATIONAL
HEALTH SERVICES
AFFAIRS
BWH Occupational Health
27
Immunization Requirements
28
Tuberculosis Screening
29
Facts on Tuberculosis
30
Work-related Illness/Injury Reporting
31
Exposure to Blood/Bodily Fluids
32
Information on HIV
33
Information on Hepatitis B
33
Information on Hepatitis C
34
Reportable Conditions
35
24
OCCUPATIONAL HEALTH SERVICES
The mission of the Occupational Health Service is to provide and promote health, safety and
well being of employees and the work environment. The Occupational Health Service (OHS)
provides pre-placement health screening for all new employees, as well as treatment for workrelated injuries and illnesses. Care is provided to employees at two locations: PBB-MidcampusGround Floor and Neville House -1st Floor.
Neville House -1st Floor: provides pre-placement health screenings, TB screenings,
immunizations, and return-to-work clearances. Human Resources Generalist teams arrange
pre-placement screenings. For more information, you can contact this clinic by calling 617-7326034 or x2-6034.
PBB-MidCampus-Ground floor OHS: provides evaluation and treatment of work-related injuries as
well as fitness for duty testing. Walk-in service is available for evaluation of any work-related
injury or illness. OHS also provides ergonomic evaluations of the work environment to ensure a
safe work environment. Finally, any employee thinking that he/she may need special
accommodations to do their job should schedule an appointment to meet with an OHS clinician.
For more information, you can contact this clinic by calling 617-732-8501 or x2-8501.
During the periods the OHS is closed, employees requiring immediate attention for work-related
injuries or illnesses should report to the Emergency Department.
The OHS does not provide episodic illness care to employees. However, OHS staff will be
happy to assist employees in selecting a primary care provider as needed. For more
information on selecting a primary care provider, you may also call the PCP Hotline at 1-800BWH-9999.
Contact Information:
Department of Occupational Health Service
Location:
Neville House- 1st Floor OHS
617-732-6034 or x2-6034
PBB-Midcampus-Ground Floor OHS:
617-732-8501 or x2-8501
Hours (both clinics):
Reporting a Work related Injury/Illness
Reporting a Blood/Body Fluid Exposure
Monday - Friday
7:00 AM – 4:30 PM
: 617-732-8501 or x2-8501
: Page 3-STIK (3-7845)
(Dial 617-732-5700, then bb#)
25
IMMUNIZATION AND SCREENING REQUIREMENTS
The following immunizations/screenings are required of BWH employees for the protection of
the employee, co-workers, and patients. All immunizations are reviewed at the pre-placement
health screening and should be updated annually, if appropriate. Testing and vaccinations can
be obtained in the Occupational Health Service, Neville House, 1st Floor. Questions can be
directed to the clinic at 617-732-6034 or x2-6034.

Tuberculosis: Employees should have received a PPD skin test within the past three months
or they will require a new PPD skin test at the pre-placement health screening. For
employees with a history of positive skin test, written documentation of your chest x-ray
evaluation will be needed.
 Employees who are 35 years and older who do not have evidence of a PPD skin test
within the past year, are required to complete a two-step test.
 All employees are required to have a TB screen on at least an annual basis. Employees
with a history of a past positive PPD skin test are required to have an annual symptom
review.

Rubella (German Measles): All employees should have either a positive antibody test or
Rubella or MMR vaccination.

Rubeola (Measles): All employees should have documentation of:
 Two live measles or MMR (measles, mumps, rubella) vaccinations given at least one
month apart if born in 1957 or after, OR, a positive antibody test.
 One live measles or MMR (measles, mumps, rubella) vaccination if born before 1957 or a
positive antibody test.

Varicella (Chickenpox): Employees should have either a reliable history of chickenpox OR a
positive antibody test OR documentation of two varicella vaccinations.

Hepatitis B: Employees who are providing direct patient care, working with live Hepatitis B
Virus, or who have potential for blood or body fluid exposure during the course of their work,
should have either a full Hepatitis B vaccination series (3 doses of vaccine) OR a positive
Hepatitis B antibody titer.

Influenza (flu): Direct patient care givers should have an annual influenza immunization
unless otherwise contraindicated. All other employees are strongly encouraged to be
vaccinated yearly. This service is provided by the Occupational Health Service.
26
TUBERCULOSIS SCREENING
Tuberculosis (TB) skin testing is vital to the hospital’s infection control efforts and is the best
indicator of whether you have been unknowingly exposed to tuberculosis in the health care
setting. Periodic testing also allows an opportunity to determine a change in your TB status
promptly so you may benefit from preventative medications, as appropriate to your general
health. The hospital requires a minimum of an annual TB skin testing for all employees.
TB skin testing is provided by the Occupational Health Service (OHS) in a two-part process.
First, the TB test is provided or “planted”. Second, your arm must be examined by an OHS
nurse or a designated TB Resource Nurse, 48 to 72 hours after the test was planted. Failure to
be tested at least annually may result in suspension of employment until you are tested.
To make TB testing easy and accessible for employees, the Occupational Health Service
provides quarterly TB testing in the Mary Horrigan Connors Lobby for one week during each
quarter. Walk-in service is also available at the OHS clinic, Neville House- 1st Floor. It is
required that employees have a TB test in the quarter in which his or her birthday falls. Letters
are sent to the homes of employees in the quarter in which the employee’s birthday falls to
remind him/her of the need for an annual TB test.
If you have a history of having a positive TB skin test, you are not required to be tested
annually, but will need to complete a questionnaire about symptoms related to TB. You will be
sent this questionnaire yearly by the OHS.
27
FACTS ON TUBERCULOSIS
What is tuberculosis?
Tuberculosis (TB) is an infection that is spread from person to person through the air. TB is
most infectious when it involves the lungs or larynx of the infected person. The TB bacteria
become airborne when a person with pulmonary or laryngeal TB coughs, sneezes, laughs or
sings. These bacteria can then be inhaled and infect others. General symptoms of TB infection
include feeling weak or sick, loss of appetite, unexplained weight loss, fever, night sweats,
chronic cough, and/or coughing up blood.
As a healthcare worker, am I at higher risk for being infected by TB?
Yes. Several hospital-based outbreaks of TB have occurred in recent years, resulting in
infections and some deaths among healthcare workers. You are particularly at risk if you are
HIV-infected.
What can be done to prevent transmission of TB?
Patients who have or are suspected of having active pulmonary or laryngeal TB must be
immediately placed in a negatively pressurized isolation room. Healthcare workers
who enter the patient’s room must wear a special TB respirator (3M N95) in the size for which
they have been fit tested. If you have not been fit tested, contact the Department of
Environmental Affairs (x2-7016) to arrange to be fit tested. In the meantime, a Powered AirPurifying Respirator (PAPR) can be used. If PAPR is not available in your area, call the
Department of Environmental Affairs for assistance.
What should be done while the patient is on Airborne Precautions for TB?
The patient must remain in a negatively pressurized isolation room and the room pressure
conversion switch must be set to negative. All doors to this room must be kept closed as
much as possible.
Can patients on Airborne Precautions for TB leave their rooms?
Patient travel outside the room should be limited to emergency procedures only. If the patient
must leave the room, s/he should wear a surgical mask. If the patient is traveling to another
area within the hospital, the appropriate personnel need to be notified so that they may take
the necessary precautions.
How long should a patient remain on Airborne Precautions for TB?
Patient must remain on Airborne Precautions until:
1.
TB has been clinically excluded as a diagnosis; OR
2.
Three consecutive sputum specimens obtained on 3 separate
days are acid fast bacilli (AFB) negative and TB has been excluded as a diagnosis; OR
3.
The patient with TB must have received anti-TB medications for
14 days AND have 3 consecutive negative sputum specimens obtained on 3 separate
days; AND show clinical and radiographic improvement.
28
REPORTING OF WORK-RELATED INJURIES/ILLNESSES
All injuries, illnesses and exposures related to work should be reported through the BWH
incident reporting system. If you need guidance with this system, your supervisor will assist
you. You should follow the guidelines below:
1.
2.
Inform your supervisor of your reportable event as soon as possible after the incident.
You must report the incident within 24 hours of the event.
Complete an incident report and report to the Occupational Health Service within 24 hours
of the event either in person or via the telephone. Email is not acceptable. The incident
report should contain:
a.
b.
c.
d.
e.
date and time
brief description
any witnesses
who you notified (supervisor)
your name and the date you completed the report
3.
If you need medical attention, immediately contact the Occupational Health Service
(OHS) at 61-732-8501 or x2-8501. If you are injured during hours the OHS is closed,
report to Emergency Services and follow-up with the OHS on the next day the OHS is
open.
4.
If you require further medical attention, work restrictions or time out of work, the OHS
will manage your case and assist you in your recovery and return to work.
29
EXPOSURE TO BLOOD OR OTHER BODY FLUIDS
All body fluids including blood are to be considered possibly infectious.
Exposure to body fluids may result from a needlestick or a splash to an open area such as the
eyes, nose and mouth, or contact with intact skin. Prompt reporting of an exposure can reduce
the risk of infection. The following steps should be taken if an exposure occurs.
1.
Clean the area- Cleansing is an important step. Clean the exposure site for five to ten
minutes based on the following options.
For needlestick: wash the site with soap and water.
For a splash to your mouth or nose: flush the area with water.
For a splash to your eyes: flush with water or saline then go to the Occupational Health
Service for irrigation.
2.
Page - Page the STIK Beeper 3-STIK (#37845). (Call 617-732-5700 or x2-5700 and
enter page #37845.) You are required to report an exposure to blood or body fluids at
the time it occurs. The hospital has established a rapid, reporting hotline for you to
report a blood or body fluid exposure. This hotline is available 24 hours a day, 7 days a
week. This hotline is activated by paging the “STIK” Beeper or 3-STIK (#37845).
You may also report by going directly to the Occupational Health Service (OHS), PBB 1.
The OHS is open Monday through Friday, from 7:00 a.m. to 4:30 p.m.
During the times the OHS is closed, page the stik beeper at 3-STIK (#37845) and then
proceed to the Emergency Department. You must also report the incident to your
supervisor and fill out an incident report.
3.
Notify your Supervisor
4.
Fill out an Incident Report
5.
Evaluation - The OHS provider will obtain information about your exposure and
recommend treatment if needed. If the exposure is high risk, medications are
available to decrease the risk. It is recommended that these medications be started
within one to two hours after the exposure. If you choose to take these medications,
the OHS will provide them to you.
30
Information on HIV
What is HIV?
HIV stands for Human Immunodeficiency Virus. This is the virus that causes AIDS (Acquired
Immunodeficiency Syndrome). HIV is found in blood, semen and vaginal secretions of an
infected person. It is a very fragile virus that will not survive outside the body for any
significant period of time.
What is the risk of transmission to HIV after an occupational exposure?
The risk of transmission for health care workers after a needlestick or puncture from a sharp
object from HIV-infected blood is .3% (1 in 300). The risk of transmission after a splash to the
eyes, nose or mouth from HIV-infected blood is approximately .1% (1 in 1000).
How can HIV infection be prevented?
There is no vaccine for HIV. Health care workers can prevent exposure to HIV by following
universal precautions and using safe needle devices appropriately. If you are exposed to
potentially infectious blood, page the STIK beeper immediately. Studies have shown that taking
anti-retroviral drugs immediately after the exposure can reduce or eliminate the transmission of
HIV.
Information on Hepatitis B Virus
What is the Hepatitis B Virus (HBV)?
Hepatitis B virus is a virus that causes liver disease. HBV is found in blood and in most body
fluids. HBV is a very strong virus and it can live on inanimate surfaces such as tables, bedside
rails and monitors for several days. Wiping surfaces with standard germicidal cleaning agents
will kill the HBV.
What is the risk of transmission to HBV after an exposure?
For non-vaccinated health care workers the risk of HBV transmission is 30-40% after a known
Hepatitis B exposure. This is approximately 100 times the risk of acquiring HIV after a
comparable exposure.
Employees who have been vaccinated and have positive antibodies are protected.
Hepatitis B is a major infectious occupational hazard to healthcare workers. Prior to the
availability of the Hepatitis B vaccine over 12,000 healthcare workers were infected every year
due to occupational exposures and approximately 200-300 healthcare workers died annually
from HBV.
How can Hepatitis B virus infection be prevented?
The Hepatitis B vaccine can prevent infection once the body has developed antibodies. The
vaccine is free to health care workers who are potentially at risk of exposure to the Hepatitis B
virus. The vaccine is safe even during pregnancy. A three dose series is required over a six31
month period. Upon completion of the series, a blood test should be done to check for
antibodies. Once the health care worker has antibodies they are protected for life and do not
need to check their antibodies again.
The Hepatitis B vaccine is free to all BWH healthcare workers who may come in contact with
blood during the course of their work. The Occupational Health Service administers the vaccine
Monday through Friday, 7:00 a.m. to 4:30 p.m. No appointment is necessary.
Information on Hepatitis C Virus
What is the Hepatitis C Virus (HCV)?
Hepatitis C (HCV) is a virus that causes liver disease. Hepatitis C is found primarily in the blood.
It is almost always spread by blood to blood routes, such as blood transfusions or needle
sharing. In less common instances, Hepatitis C can be transmitted via sexual intercourse or via
mother to child.
What is the risk of transmission after an occupational exposure?
The risk of occupational transmission following a known HCV exposure is approximately 2-10%.
How can Hepatitis C infection be prevented?
Unlike Hepatitis B, there is no vaccine for Hepatitis C. Health care workers can prevent
exposure to Hepatitis C by following universal precautions and using safe needle devices
appropriately.
The number of new cases of HCV in the general public has declined in the past 10 years as a
result of more sensitive testing of donated blood and reduced sharing of needles by IV drug
users.
32
REPORTABLE CONDITIONS
The following is a list of potentially infectious conditions that you are required to report to the
Occupational Health Service (OHS), Neville House, 1st floor- (617) 732-6034 (x2-6034). If you
think you have a condition or illness not listed here that may be infectious, you should report
this so that an assessment of communicability can be done. This is an important step in
minimizing spread of infectious conditions to co-workers and patients.
Chickenpox
Conjunctivitis (pink eye)
Gastrointestinal illness (Salmonella, Shigella, Giardia, and other types of food poisoning)
German Measles (Rubella)
Hepatitis A
Influenza
Measles
Meningitis
Mumps
Pertussis (Whooping Cough)
Scabies and lice exposures and/or infections
Shingles
Any skin rash or lesions (contact dermatitis)
Staph skin infection
Strep throat and/or skin infection
Tuberculosis
33
BWH PATIENT
SAFETY TEAM
Patient Safety Team
37
Patient Safety Terminology
38
Medication Safety
39
34
BWH PATIENT SAFETY TEAM
The goal of the Patient Safety Team is to make BWH as safe as possible by reducing
preventable medical errors. The team intends to foster a culture that encourages and rewards
the open identification, communication and resolution of safety issues. The team intends to
provide for organizational learning from adverse events and from evidence-based best practice
in efforts to reduce preventable medical errors.
The Patient Safety Team is integrated within Quality Management Services and works
collaboratively with Risk Management, Performance Measurement, Care Improvement,
Corporate and Regulatory Compliance, Patient and Family Relations, Nursing Management and
Pharmacy. Patient Safety reports directly to the Chief Medical Officer and also reports issues
through the Care Improvement Council, Hospital Safety and Environment of Care Committee,
and the Medical Staff Executive Committee on Quality Assurance and Risk Management.
Contact information:
Patient Safety Office: 617-732-7543 or x2-7543
Patient Safety Team:
Director: Tejal Gandhi, MD, MPH
Patient Safety Manager: Erin Graydon-Baker, MS, RRT
Adverse Drug Event Pharmacist: Carl Stapinski, R.Ph
Patient Safety Research Assistant: Camilla Neppl
Location:
Hours:
54 Francis St. T4
Monday – Friday, 8:00am-4: 30pm
Note: If you have an urgent patient safety concern during the hours that the Risk Management
or Patient Safety office are closed, telephone the hospital administrator on call for immediate
assistance.
35
PATIENT SAFETY TERMINOLOGY
Since the release of the 1999 Institute of Medicine report, there has been a heightened
awareness of medical errors and an increase in publications advocating patient safety. To clarify
some of the patient safety terminology, we’ve included a glossary of the most commonly used
terms.
Medical Error
An unexpected, unintended act that does not achieve it’s intended outcome
(adverse patient event).
Near Miss
An adverse event that does not result in patient injury, but by it’s very
nature, identifies systems issues that require a full review and analysis.
Sentinel Event
An unexpected occurrence involving death or serious physical or
psychological injury.
Root Cause Analysis The process of reviewing systems that have contributed to the sentinel
event.
Human Factors
The interrelationships between humans, the tools they use and the
environment in which they work.
Adverse Drug Event An injury due to a drug (can be preventable or non-preventable). Nonpreventable adverse drug events are also called adverse drug reactions.
36
MEDICATION SAFETY
Medication errors are one of the most reported areas of adverse events. Clinicians who
prescribe, transcribe, dispense and or administer medications should refer to the medication
safety on-line references including the BWH Drug Administration Guidelines (DAG) and
Formulary, Physicians Desk Reference and Micromedex.

To access DAG and/or Formulary from your Windows desktop, click ‘Start’, then ‘Clinical
References’, then ‘BWH Pharmacy Information Resources’, and click either ‘BWH Medication
Formulary’ or ‘Drug Administration Guidelines’ (located on the left side of the screen) based
on your needs.

To access the Physicians Desk Reference from your Windows desktop, click ‘Start’, then
‘Clinical References’, then ‘Physicians Desk Reference’ (Micromedex).
Reference to the Pharmacy Information Resources and attention to the “5 R’s” will enhance
medication safety.
The “5 R’s” of medication safety are:
 Right patient
 Right medication
 Right dose
 Right route of administration
 Right time
37
BWH RISK
MANAGEMENT
DEPARTMENT
BWH Risk Management Dept.
41
Incident Reporting
42
38
BWH Risk Management Department
Healthcare Risk Management at BWH focuses on identification, evaluation and treatment of
problems that arise in the course of providing medical treatment to patients that might result in
serious patient injury or the potential of financial loss to the health care institution or providers.
The main objectives of risk management include improving the quality of care provided to
patients, promoting a patient-safe environment, and as a result, preventing or minimizing the
risk of liability exposure.
As an employee at BWH, staff have two major roles in risk management:
 Respond to adverse patient events in an appropriate and timely manner and report those
events promptly to the Risk Management Department in accordance with hospital policy.
 Develop and use strategies aimed at improving patient safety, preventing medical errors
and professional liability claims.
The Risk Management Department investigates and reviews adverse patient events, facilitates
the root cause analysis process to identify sentinel events, and assists in recognizing quality
improvement issues, etc. Additionally, the department is responsible for fulfilling the Hospital’s
obligation to report certain patient events to both state and federal regulatory agencies,
including the Board of Registration in Medicine and the Department of Public Health.
Participation of BWH employees is crucial when it comes to prompt recognition and notification
of a serious adverse patient occurrence.
The Risk Management Department must be notified promptly if you receive or are served with
formal suit papers (Summons and Complaint) or subpoena. The department will provide
information and guidance on responding to such documents. In general, you should only
accept a summons or subpoena if you are the person named, or if you serve the function
named, i.e., “Keeper of Records”, or if the person named has specifically authorized you to
accept service on his/her behalf.
Finally, notify the Risk Management Department if you receive any communication from an
attorney requesting information about patients or you receive notice of or threat of legal action
or demand for compensation in connection with providing healthcare while at BWH.
Contact Information:
Director of Risk Management:
Risk Management Department:
Location:
Hours:
Janet Barnes
617-732-6442 or x2-6442, Beeper 11775
PBB- MidCampus, 3rd Floor
Monday – Friday, 8:00 AM – 4:30 PM
39
Incident Reporting
BICS Incident Reporting System
In the BICS system, under Clinical Information “CI”, elect option “Q”.
Choose Enter/Edit and enter information about the incident at each computer prompt. Indicate
whether the subject of the event is a patient or visitor, and follow the computer prompts.
(Enter eight zero’s for a patient number and the system will allow you to enter a test report that
will not be aggregated.) Each incident type has its own core “shell” of questions based on the
information most relevant in serving both quality improvement and risk management goals. An
employee injury or accident should be reported using the paper form for employee incidents.
It is important that all incident report forms be filled out accurately and completely.
Tips to remember with incident reporting:
A)
B)
C)
D)
E)
F)
G)
H)
The purpose is to address systems issues and not to assign blame.
Put quality of care first; Give incident reporting high priority.
Take responsibility for reporting.
Report immediately; Write it up before the end of your shift.
Notify your supervisor of the incident.
Try to only articulate the facts. Report what you saw, heard and did.
Quote what a patient or visitor says about an incident, if possible.
Don’t document in the patient’s records that an incident report has been filled out, or that
Risk Management has been contacted. Only clinically pertinent information should be
documented.
A serious incident occurring when the Risk Management office is closed should be reported by
telephone to the hospital administrator on call by dialing the page operator.
When in doubt about reporting, contact the BWH Risk Management Department at x2-6442 or
contact Janet Barnes at 617-732-8394 or x2-8394 or on Brigham Beeper 11775 (Dial 617-7325700 or x2-5700, then bb#11775).
40
BWH
SECURITY
BWH Security Department
44
41
SECURITY
Contact Information:
Department of Security:
Location:
Hours:
617-732-6565 or x2-6565
Surgical Building, 1st Floor
24 hours/day, 7 days/week
Emergency Situation "Code Grey"
An emergency situation potentially requiring intervention by security is referred to as ‘Code
Grey’. Code Grey will be announced by overhead page with the location of the incident or
condition. If you see an incident or condition that you believe requires the intervention of
security officers, call 617-732-6555 or x2-6555 (Stat Operator), give the exact location and wait
for the operator to verify the information given before hanging up.
Security Services are provided by Pinkerton Security. Interior and exterior security officer
patrols are dispatched through a control center 24 hours/day, seven days/week. The control
center also monitors a computerized alarm/closed circuit television system, which protects the
perimeter of the hospital as well as various interior areas and buildings adjacent to or detached
from the main campus/tower complex.
Bomb Threat “Code White”
If you receive a bomb threat, try to obtain as much information from the caller as possible.
Report the threat immediately by calling the Stat line at 617-732-6555 or x2-6555.
For the following situations, please contact Security at 617-732-6565 or x2-6565.
 Reporting Incidents
 Observe Suspicious individual(s) or activity
 Find yourself in or witness a confrontational situation
 Other incidents that require security assistance or that you believe are worthy of reporting
 Trust your own feelings and judgement regarding whether an incident should be reported
Infant Abduction “Code Pink”
A Code Pink should be called anytime a staff member believes that an infant has been, or is
about to be, abducted. Call 617-732-6555 or x2-6555 immediately and state "Code Pink and
your location".
Other Security Assistance:




To Open a Locked Dept. Door
Property Removal
Security Escorts (24hrs/ 7days)
Lost and Found


Installation of a Digital Lock or requesting
a Master Key
Securing equipment (computers,
typewriters, printers, etc.)
Security Administration (on call)
If you are dissatisfied with the service provided or feel your request was not properly
complied with or have a complaint as regards to the Security staff, contact Beeper
#13102, 24 hours/day. (Dial 617-732-5700 or x2-5700, then bb#13102).
42
REPAIR/REMOVAL OF SPECIFIC EQUIPMENT
CONTACT INFORMATION
EKG Machines
Bio-Medical
617-732-8889 or (x2-8889)
Food Trays
Dietary Needs
IV Poles
Patient Chairs (rolling)
Linen
Linen Carts
Linen Hampers
Trash
Equipment Moves:
Mattresses
Oxygen Tanks
Patient Beds
Stretchers
Wheelchairs
(and other objects to be
moved off the floor)
Dietary
617-732-7120 or (x2-7120)
Engineering
617-732-6720 or (x2-6720)
Linen
617-732-4976 or (x2-4976)
Environmental
Services
Central Transport
617-732-7130 or (x2-7130)
617-732-7117 or (x2-7117)
43
Failure of:
BUILDING SYSTEMS FAILURES & CONTACTS
Who to Contact:
Computer Systems
Information Systems
617-732-5927 or (x2-5927)
Domestic Water
Potable Water
Non-Potable Water
Electrical Power
Engineering
617-732-6720 or (x2-6720)
Engineering
617-732-6720 or (x2-6720)
Elevators
Engineering
617-732-6720 or (x2-6720)
Fire Alarm System
Engineering
Security
DEA
Engineering
Respiratory
Engineering
617-732-6720
617-732-6565
617-732-7016
617-732-6720
617-732-6593
617-732-6720
Natural Gas
Leak/Failure
Negative Pressure
Isolation Rooms
Nurse Call System
Engineering
617-732-6720 or (x2-6720)
Engineering
617-732-6720 or (x2-6720)
Engineering
617-732-6720 or (x2-6720)
Patient Care
Equipment
Sewer
Biomedical
Engineering
Engineering
617-732-8889 or (x2-8889)
Steam
Engineering
617-732-6720 or (x2-6720)
Telephones
Telecommunications
617-732-6642 or (x2-6642)
Ventilation
Engineering
617-732-6720 or (x2-6720)
Medical Gases
Medical Vacuum
or (x2-6720)
or (x2-6565)
or (x2-7016)
or (x2-6720)
or (x2-6593)
or (x2-6720)
617-732-6720 or (x2-6720)
44